7252 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• .'BUILDING PROJECT IDENTI FIC AT ON. PERMIT NUMBER
APPLICATION & PERMIT• ,
$ORUirvG : 7252
AooREsa
L BUILDING — ELECTRICAL—PLUMBING —MECHANICAL
OwNER'$ . i'L xs * "S PLAN CHECK VALIDATION
/ NAME DTY. EL"ECTRICIPbERMIT FEE
CDNTHaciDRs
PHONE � :w.:
� • • Iw ''
rvaffm��E -OUTLETS-SWITCHES-RECEP 5.00/1.00
1� 7� Lic.No. 9 �� LIGHTING FIXTURES 5.00/1.00
'ADDTRACrona - APPLIANCES-RESIDENTIAL 4.00 '
ADDRESS )
` fixPHONE �� r PANELS , ' 5.00 'DATE OF APPLICATION
OORRCNRECi it SIGNS 6,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No, SIGNS TRANS:' 3.00
ARCHEOR ENG., SPECIAL CIRCUIT _-5.00 ,.• - PERMIT VALIDATION
Z" EMP.METER.OR POL'E'INS. 15.00 a'
AMOTORS - -' SEE FEE SCH.
DRESS E$$
ADOR
SERVICE CHANGE - 10.00
w ¢i - �'''ppp/ '
.r O O _ LICENSED CONTRACTORS DECLARATION ryv/„�L?']'^.
a V v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUAN E ATE
Z (commercin with Section 7000)of Division 3 of Um Business and
A g
y BLDG. ELECT. PLG. MECH.
r N z Professions C` ,-rad m license is in full force and effect .❑ ❑ ❑
Q z m o License C Lic.Nwnber
Date Contmctor /
a >< -' 'BOIL`DING PERMIT
_¢ ¢ w u OWNER-BUILDER DECLARATION' -t ... l+
� p
X ;, , '1 hereby affirm that I am exempt from the Contractor's License MISC.— 'REFER TO ORD 1�'FI�-+: INFQR-MATIUN
FUOJ Law for the following reason.(See.7031.5,Businessind Professions PERMIT ISSUANCE600 VALUATION S/FT.
w i Code:Any city or county which requires'a permit to consnoct,aller,
.
¢ ¢¢ D improve,demolish,or repair any structure,prior to its issuance;also ELED.CONTR. LIC.NO. ELEC.
ar O¢ requires the applicant for such permit to file a signed statement that TOTAL .
.6w m” he is licensed pursuant to the provisions of the Contractor's License
• - - - PERMIT TO
r r
Law(Chapter 9(connnencing with Section 7000)of Division 3 of then."a 4'Id "'�'r Nti `.5S'"w:'�'^+`'* 'N
F i o Business and Professions Code)or that he is exempt therefrom and CITY,!y. �' B PL^UMBINGLPERMIT C.y`y"+•" FEE
r m the basis for the alleged exemption Any violation of Section 7031 5 5 �"•+• "a max'�r6 v.
,4.,LM
¢ - STORIES TYPE CONSTR.
Le ; _ by any applicant for a permit subjects the applicant ton civil Penalty -
ofeet morethan fivehundreddollars 1E500)J:- ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ I,as owner of the property,ser my employees wi0i wages as BACK FLOW PROTECT:DEVICE 2.00 ;
their mile compensation,will do the work,and the,fracture is riot OCG GROUP AES.UNITS
intended or offered for to(Sec. 7044, Business and Professim)s DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:'rhe Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 Q $p.FT.FLOOR AREA TOTAL ACREAGE
�'� himself or through his own employees,provided that such improve-
; ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 4e�•'
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) _ 1,00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.). - - INDUSTRIAL WASTE INTER. 20,00 RES INC CON APB Other
❑ 1,as owner of the Property,ani exclusively Contracting with ❑ * ❑ ❑ ❑ ❑
licensed contractors to construct the Project(See.7044,Business LAWN SPRINKLERS'-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) '1,00
contracts for such projects with a COLUT lor(s)licensed pursuant to - SEWER-SANITARY-STORM Eq.2TRACT NO. PARCEL NO.
00ft/g.00 '�'
the Contractor's License Law. '
❑ lain exempt under Sec. ,B.&P.C.for this WATER HEATER W/ T
reason 4.00 -
Owner Date WATER'SYSTEM _ -r 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPFNSAI'ION DECLARATION WATER TREATI r •E,QUIR'I PYv 4,00 ,
I hereby uffinn that I have,.certificate ofeonsent to self-insure,' -
or a Certificate ofWorkers'Compensation Insurance,or a certified ZONING ENG.SITE NO. -
copy thereof(Sec.
3800,Le)LC.L It 0
Policy No. Company -
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
F O Applicant _ _ Y ❑ N Y ❑ N❑
jr Lo CE RTI FICAT Ii O F F:X FM I'1'ION I'ROM WORKERS" PERMIT ISSUANCE 6.00FLOOD ZONE A.L.U.C.
W > COAIPIINSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
C• 0, (This Section need not be completed if the permit is for one TOTAL Y❑ IN C] Y p IN
:) Z Is u n died dollars IS 100)or less) � ' y... -
U O I certify that in the performance of the work for which this per.
FEE SUMMARY
LL F mit is usual,I shall not employ any person in any manner& as to )OTY. fuIECHANI are PERMIT FEE
O w become subject.)the Workers'J:q(i(p w.uon,Lx o, ali(o� src�` ... v,
y Dat Applicant / '�" i.a� ALTER OR ADD TO MECH. 4.00 BUILDING.
} N NOTICE-TO APPLICANf If,after making rs Certificate of Cx
♦— Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,00012—F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
The performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 Certify that I have read this application and State that the above VENTILATION FAN (SINGLE) 3.00 ^� _
information s n correct. I agree to comply with all city unit county BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING UX
ordinances and state laws relating to Building all
city and co and
hereby authorize representatives of this city to�emm,upon the BOILER-COMP Onor 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against.liabilities,judgments,costs and expenses which CONST.TAX
may i ny way se
en'
gainst Said City in consequence of the PERMIT ISSUANCE 3.00 _
g�iq Oft lis� / MECH.CONT. LIC.NO. MECH.
1,���
/ � TOTAL 'Y Jlrppa� rao�i Date a„TOTAL
OFFICE COPY ,